Ch.13
A pregnant woman comes to the emergency department stating she thinks she is in labor. Which assessment finding concerning the pain will the nurse interpret as confirmation that this client is in true labor? Radiates from the back to the front Slows when the woman changes position Occurs in an irregular pattern Lasts about 20 to 25 seconds
Radiates from the back to the front Contractions that begin in the back and then radiate to the front are typical of true labor. Contractions that slow when a woman walks or changes position suggest false labor, as do irregular contractions. ( Braxton hicks) Contractions lasting 30 seconds or less commonly suggest Braxton Hicks contractions and are associated with false labor.
A client has just given birth to a healthy baby boy, but the placenta has not yet delivered. What stage of labor does this scenario represent? First Second Third Fourth
Third Rationale: Stage three begins with the birth of the baby and ends with delivery of the placenta.
The nurse is assessing a pregnant client at 37 weeks' gestation and notes the fetus is at 0 station. When questioned by the client as to what has happened, the nurse should point out which event has occurred? flexion engagement extension expulsion
engagement Rationale: The movement of the fetus into the pelvis from the upper uterus is engagement. This is the first cardinal movement of the fetus in preparation for the spontaneous vaginal delivery. Flexion occurs as the fetus encounters resistance from the soft tissues and muscles of the pelvic floor. Extension is the state in which the fetal head is well flexed with the chin on the chest as the fetus travels through the birth canal. Expulsion occurs after emergence of the anterior and posterior shoulders.
The nurse is determining how often contractions occur measuring from the beginning of the one contraction to the beginning of the next contraction. The nurse documents this finding as: duration. intensity. frequency. peak.
frequency Rationale: Frequency refers to how often the contractions occur and is measured from the beginning of one contraction to the beginning of the next contraction. Duration refers to how long a contraction lasts and is measured from the beginning of one contraction to the end of that same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine pressure catheter. The peak or acme of a contraction is the highest intensity of a contraction.
The nurse is teaching a prenatal class on the difference between true and false labor contractions. The nurse determines the session is successful when the class correctly chooses which factor as an indication of true labor contraction? increase even if relaxing and taking a shower remain irregular with the same intensity subside when walking around and use the lateral position cause discomfort over the top of uterus
increase even if relaxing and taking a shower Rationale: True labor contractions do not stop; they continue and strengthen, as well as increase in frequency. If the contractions subside while taking a shower or relaxing, then they are not labor contractions. The discomfort over the top of the uterus is normal for full term pregnancy.
During the second stage of labor, a woman is generally: very aware of activities immediately around her. anxious to have people around her. no longer in need of a support person. turning inward to concentrate on body sensations.
turning inward to concentrate on body sensations. Rationale: second-stage contractions are so unusual that most women are unable to think of things other than what is happening inside their body.
When caring for a client in the third stage of labor, the nurse notices that the expulsion of the placenta has not occurred within 5 minutes after birth of the infant. What should the nurse do? Nothing. Normal time for stage three is 5 to 30 minutes. Notify the primary care provider of the problem. Increase the IV tocolytic to help in expulsion of the placenta. Do a vaginal exam to see if the placenta is stuck in the birth canal.
Nothing. Normal time for stage three is 5 to 30 minutes. Rationale: Following birth, the placenta is spontaneously expelled within 5 to 30 minutes, so there is no problem with this client. No further interventions are needed.
Assessment of a woman in labor reveals that the scapula of the fetus is the presenting part. The nurse interprets this finding as indicating which fetal presentation? cephalic vertex breech shoulder
Rationale: The three main fetal presentations are cephalic or vertex, with the head as the presenting part, breech, with the pelvis as the presenting part, and shoulder, with the scapula as the presenting part.
When teaching a group of nursing students about the stages of labor, the nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation? crowning effacement dilation (dilatation) molding
effacement Rationale: The nurse is explaining about effacement, which involves softening, thinning, and shortening of the cervical canal. Dilation (dilatation) refers to WIDENING of the cervical os from a few millimeters in size to approximately 10 cm wide. Crowning refers to a point in the maternal vagina from where the fetal head cannot recede back after the contractions have passed. Molding is a process in which there is overriding and movement of the bones of the cranial vault, so as to adapt to the maternal pelvis.
A client experiencing contractions presents at a health care facility. Assessment conducted by the nurse reveals that the client has been experiencing Braxton Hicks contractions. The nurse has to educate the client on the usefulness of Braxton Hicks contractions. Which role do Braxton Hicks contractions play in aiding labor? These contractions help in softening and ripening the cervix. These contractions increase the release of prostaglandins. These contractions increase oxytocin sensitivity. These contractions make maternal breathing easier.
These contractions help in softening and ripening the cervix. Braxton Hicks contractions assist in labor by ripening and softening the cervix and moving the cervix from a posterior position to an anterior position. Prostaglandin levels increase late in pregnancy secondary to elevated estrogen levels; this is not due to the occurrence of Braxton Hicks contractions. Braxton Hicks contractions do not help in bringing about oxytocin sensitivity. The occurrence of lightning, not Braxton Hick's contractions, makes maternal breathing easier.
The nurse notes that the fetal head is at the vaginal opening and does not regress between contractions. The nurse interprets this finding as which process? engagement descent restitution crowning
Crowning rationale: Crowning occurs when the top of the fetal head appears at the vaginal orifice and no longer regresses between contractions. Engagement occurs when the greatest transverse diameter of the head passes through the pelvic inlet. Descent is the downward movement of the fetal head until it is within the pelvic inlet. Restitution or external rotation occurs after the head is born and free of resistance. It untwists, causing the occiput to move about 45 degrees back to its original left or right position.
A nurse is providing care to a woman in labor. When reviewing the woman's medical record, the nurse notes that fetal position is documented as LSA. The nurse interprets this to mean that which part of the fetus is presenting? occiput buttocks chin acromion process
buttocks Rationale: The second letter of LSA denotes the presenting part. In this case, it is "S" which is for sacrum or buttocks. "O" refers to the occiput; "M" would be used to refer to the chin. "A" would be used to refer to the acromion process.
A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign marks the TERMINATION of the first stage of labor in the client? diffuse abdominal cramping rupturing of fetal membranes start of regular contractions dilation (dilatation) of cervix diameter to 10 cm
dilation (dilatation) of cervix diameter to 10 cm Rationale: The first stage of labor TERMINATES with the dilation (dilatation) of the cervix diameter to 10 cm. Diffused abdominal cramping and rupturing of the fetal membrane occur during the first stage of labor. Regular contractions occur at the beginning of the latent phase of the first stage; they do not mark the end of the first stage of labor.
The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. How should the nurse document this finding? presentation attitude lie position
lie Rationale: The nurse is assessing fetal lie, the relationship of the fetal long axis to the maternal long axis. When the fetal long axis is longitudinal to the maternal long axis, the lie is said to be longitudinal. Presentation is the portion of the fetus that overlies the maternal pelvic inlet. Attitude is the relationship of the different fetal parts to one another. Position is the relationship of the fetal denominator to the different sides of the maternal pelvis.
Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting? shoulders occiput brow buttocks
occiput Rationale: With a vertex presentation, a type of cephalic presentation, the fetal presenting part is the occiput. The shoulders are the presenting part when the fetus is in a shoulder presentation. The brow or sinciput is the presenting part when a fetus is in a brow presentation. The buttocks are the presenting part when a fetus is in a breech presentation.
The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out "0 station" refers to which sign? This is just a way of determining your progress in labor." "This indicates that you start labor within the next 24 hours." "This means +1 and the baby is entering the true pelvis." "The presenting part is at the true pelvis and is engaged.
"The presenting part is at the true pelvis and is engaged." Rationale: 0 station is when the fetus is engaged in the pelvis, or has dropped. This is an encouraging sign for the client. This sign is indicative that labor may be beginning, but there is no set time frame regarding when it will start. Labor has not started yet, and the fetus has not begun to move out of the uterus.
During which time is the nurse correct to document the end of the third stage of labor? Following fetal birth When pushing begins At the time of placental delivery When the mother is moved to the postpartum unit
At the time of placental delivery Rationale: The third stage of labor concludes with the delivery of the placenta. The nurse is correct to document that time in the medical record. The beginning of the third stage of labor is the documented time of birth. Neither the time when the woman begins to push nor when she is moved to the postpartum unit are notable.
The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation? Admission time and time of fetal birth Complete cervical dilation (dilatation) and time of fetal birth Effacement time and time when contractions are regular Time of mucus plug expulsion and full cervical dilation
Complete cervical dilation (dilatation) and time of fetal birth The second stage of labor begins with complete cervical dilation (dilatation) of 10 cm and ends with delivery of the neonate.
Which nursing action is a priority when the fetus is at the +4 station? Have a blue bulb suction and an infant warmer ready. Have a tocometer and a client gown ready. Provide lubricating jelly and an internal monitor. Prepare for an immediate cesarean birth.
Have a blue bulb suction and an infant warmer ready. Rationale: At +4 station, the fetus is being born. The priority nursing action is to have a blue bulb or suction device for airway clearance and an infant warmer ready. During admission, the nurse will place a tocometer on the maternal stomach and have a gown ready. For checking effacement and dilation (dilatation), the nurse will have a lubricant and possibly an internal monitor per health care provider orders. A cesarean birth is not needed as the fetus has progressed through the birth cana
A primigravida client at 38 weeks' gestation calls the clinic and reports, "My baby is lower and it is more difficult to walk." Which response should the nurse prioritize? "The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks." "This is not normal unless you are in active labor; come to the hospital and be checked." "That is something we expect with a second or third baby, but because it is your first, you need to be checked." "The baby moved down into the pelvis; this means you will be in labor within 24 hours, so wait for contractions then come to the hospital."
"The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks." rationale: The baby can drop into the pelvis, an event termed lightening, and can happen for up to 2 weeks before the woman goes into labor. This is normal and does not require intervention.
The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth? -5 0 +1 +4
0 Rationale: As the fetus is being born, the fetus is at +4 station. The fetus is floating and not engaged in the pelvis at -5 station. The fetus is at the level of the ischial spines and engaged at 0 station. The fetus is progressing down the birth canal below the ischial spines at +1 station.
A woman at 38 weeks' gestation is in labor and oxytocin is prescribed to augment her labor. When preparing to administer this medication, what action by the nurse would be appropriate? Give the medication as an intramuscular injection using the Z-track technique. Administer the medication piggybacked into a primary IV line using a pump. Give the medication orally every hour for the first 4 hours.' Assist with insertion of a central venous access device for administration.
Administer the medication piggybacked into a primary IV line using a pump. Synthetic oxytocin is used to induce or augment labor by stimulating uterine contractions. It is administered piggybacked into the primary intravenous line with an infusion pump titrated to uterine activity. It is not given orally, via IM injection, or through a central venous access device.
The nurse is caring for a client who is experiencing a noneventful labor process. Which assessment findings may occur as the client progresses through the stages of labor? Select all that apply. Dry mucous membranes Nausea Diuresis Increased white blood cell count Increased urine specific gravity Hyperventilation
Dry mucous membranes Nausea Increased white blood cell count Increased urine specific gravity Hyperventilation Rationale: The nurse is correct to identify that normal changes occur during the labor process. Due to mouth breathing and drinking limited fluids, if any, dehydration with dry mucous membranes and an elevated urine specific gravity are common. Since labor prolongs gastric emptying, the client may experience nausea. An increase in the white blood cell stemming from the immune response is common. Concentrated urine and decreased urine production are common, not diuresis.
A client calls the prenatal clinic and tells the nurse, "I think I am in labor." The nurse determines that the client is in true labor based on which client statement? "I feel pressure in my vagina when I have the contraction." "I will have a strong one and then the next one will be weaker." "I feel the tightening primarily in the front of my belly." "The contractions lessen after I drink a large glass of water."
"I feel pressure in my vagina when I have the contraction." Rationale: True labor is characterized by contractions occurring at regular intervals that increase in frequency, duration, and intensity. True labor contractions bring about progressive cervical dilation and effacement. True labor contractions are regular, becoming closer together, getting stronger with time with pressure in the vagina being felt. In contrast, false labor contractions are usually felt in the front of the abdomen, alternate in intensity (strong one followed by a weaker one), and diminish with activity, position changes, and drinking fluids.
Braxton Hicks contractions are termed "practice contractions" and occur throughout pregnancy. When the woman's body is getting ready to go into labor, it begins to show anticipatory signs of impending labor. Among these signs are Braxton Hicks contractions that are more frequent and stronger in intensity. What differentiates Braxton Hicks contractions from true labor? Braxton Hicks contractions get closer together with activity. Braxton Hicks contractions usually decrease in intensity with walking. Braxton Hicks contractions do not last long enough to be true labor. Braxton Hicks contractions cause "ripening" of the cervix.
Braxton Hicks contractions usually decrease in intensity with walking. Rationale: Braxton Hicks contractions occur more frequently and are more noticeable as pregnancy approaches term. These irregular, practice contractions usually decrease in intensity with walking and position changes.
The client in active labor overhears the nurse state the fetus is ROA. The nurse should explain this refers to which component when the client becomes concerned? Fetal station Fetal attitude Fetal position Fetal size
Fetal position Rationale: When documenting the ROA, this is the right occiput anterior or the relationship of the fetal position to the mother using the maternal pelvis as the point of reference. Fetal station refers to the relationship of the presenting part of the fetus to the ischial spines of the pelvis. Fetal attitude refers to the relationship of the fetal parts to one another. Fetal size refers the actual size of the developing fetus.
The nurse is caring for a client at 39 weeks' gestation who is noted to be at 0 station. The nurse is correct to document which? The client is fully effaced. The fetus is floating high in the pelvis. The fetus is in the true pelvis and engaged. The fetus has descended down the birth canal.
The fetus is in the true pelvis and engaged. When the fetus is at a 0 (zero) station, it is at the level of the ischial spines and said to be engaged. Determining the station does not mean that the client's cervix is fully effaced. If the fetus is floating high in the pelvis, its station is noted as a negative number. Descending into the pelvis or birth canal is documented as a positive number.
To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest? lying supine with legs in lithotomy stirrups squatting while holding her breath head elevated, grasping knees, breathing out lying on side, arms grasped on abdomen
head elevated, grasping knees, breathing out Rationale: For the most effective pushing during the second stage of labor, a woman should wait to feel the urge to push even though a pelvic exam has revealed she is fully dilated. Pushing is usually best done from a semi-Fowler's position with legs raised against the abdomen, squatting, or on all fours rather than lying flat to allow gravity to aid the effort . Make sure the woman pushes with contractions and rests between them. She can use short pushes or long, sustained ones, whichever feels more comfortable. Holding the breath during a contraction could cause a Valsalva maneuver or temporarily impede blood return to her heart because of increased intrathoracic pressure, which could then also interfere with blood supply to the uterus. To prevent her from holding her breath during pushing, urge her to grunt or breathe out during a pushing effort (as tennis players do).
A nurse is teaching a group of pregnant women about the signs that labor is approaching. When describing these signs, which sign would the nurse explain as being essential for effacement and dilation (dilatation) to occur? cervical ripening and softening Braxton Hicks contractions bloody show lightening
cervical ripening and softening The ripening and softening of the cervix that result from the effects of prostaglandins and pressure from Braxton Hicks contractions are essential for effacement and dilation (dilatation) of the cervix. Lightening occurs when the fetal presenting part begins to descend into the true pelvis. Bloody show occurs as the mucus plug is expelled as a result of cervical softening and increased pressure of the presenting part.
What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor? The client's cervix is fully dilated. The infant is born. The client has contractions once every two minutes. The client experiences her first full contraction.
The client's cervix is fully dilated. Rationale: The first stage of labor ends with the client's cervix being fully dilated at 10 cm. The onset of contractions signals the beginning of the first stage and birth occurs at the end of the second stage.
A pregnant woman at 37 weeks' gestation calls the clinic to say she thinks that she is in labor. The nurse instructs the woman to go to the health care facility based on the client's report of contractions that are: occurring in the abdomen and groin. lasting about 30 seconds. occurring about every 5 minutes. relieved by walking.
occurring about every 5 minutes. The nurse needs to determine if the client is experiencing true labor contractions. True labor contractions are commonly felt in the lower back, in contrast to Braxton Hicks contractions that typically last about 30 seconds and occur primarily in the abdomen and groin and are relieved by walking, voiding, eating, increasing fluid intake, or changing positions. However, if contractions last longer than 30 seconds and occur more often than 4 to 6 times per hour, the nurse should have the woman evaluated, especially if she is less than 38 weeks' pregnant.